Detailed presentation about classification, evaluation and treatment of voiding dysfunctions by Prof.Dr.Tarek Osman

1. Voiding DysfunctionVoiding Dysfunction
A Simple ApproachA Simple Approach
Towards UnderstandingTowards Understanding
and Managementand Management
Tarek Osman M.D.Tarek Osman M.D.
Professor, UrologyProfessor, Urology Department,Department, Ain-ShamsAin-Shams
UniversityUniversity
Cairo, Egypt.Cairo, Egypt.

5. NeurophysiologyNeurophysiology

6. Pontine Micturition
Center
(Maestro)
Lower UT (Bladder &Urethra)
Higher Cortical centers (CC,
Hypoth, Cerebellum)
Pontine Voiding Center (M region)
Pontine Storage Center (L region)
Storage Reflex
Voiding Reflex

7. Storage ReflexStorage Reflex
 InputInput: Ascending Impulses: Ascending Impulses
from the urothelium via Afrom the urothelium via A
δδ fibers and C fibers infibers and C fibers in
pelvic nerve & Descendingpelvic nerve & Descending
impulses from higherimpulses from higher
centerscenters
 CenterCenter PMC –L regionPMC –L region
 OutputOutput
1.1. Stimulation of SympatheticStimulation of Sympathetic
outflow Toutflow T 1010-L-L11
Hypogastric nerveHypogastric nerve
2.2. Inhibition of the P.SympInhibition of the P.Symp
outflow from Soutflow from S 2,3,42,3,4 (Pelvic(Pelvic
nerve)nerve)
3.3. Stimulation of the outletStimulation of the outlet
Center SCenter S 2,3,42,3,4 (Onuf n.)(Onuf n.)
(Pudendal nerve)(Pudendal nerve)
Symp T10-L1
P.Symp S2,3,4
(Interomed)
Motor S2,3,4
(Onuf)

8. Voiding ReflexVoiding Reflex
 InputInput:: Ascending ImpulsesAscending Impulses
from the urothelium &from the urothelium &
Descending impulses fromDescending impulses from
higher centershigher centers
 CenterCenter PMC –M regionPMC –M region
 OutputOutput
1.1. Inhibition of SympatheticInhibition of Sympathetic
outflow Toutflow T 1010-L-L11 HypogastricHypogastric
nervenerve
2.2. Stimulation of the P.SympStimulation of the P.Symp
outflow from Soutflow from S 2,3,42,3,4 (Pelvic(Pelvic
nerve)nerve)
3.3. Switch off the outlet CenterSwitch off the outlet Center
SS 2,3,42,3,4 (Onuf n.) (Pudendal(Onuf n.) (Pudendal
nerve)nerve)
Symp T10-L1
P.Symp S2,3,4
(Interomed)
Motor S2,3,4
(Onuf)

9. Categorization of VoidingCategorization of Voiding
DysfunctionsDysfunctions
Several Classifications….Several Classifications….
 Clinical, Urodynamic,Clinical, Urodynamic,
Pathophysiologic, Anatomical…Pathophysiologic, Anatomical…

10. Functional Classification (Functional Classification (WeinWein((
Failure to StoreFailure to Store
Because of the BladderBecause of the Bladder
 OveractivityOveractivity
1.1. Involuntary contractionInvoluntary contraction
2.2. Decreased ComplianceDecreased Compliance
3.3. CombinationCombination
 Hypersensitivity (inflam, psych…)Hypersensitivity (inflam, psych…)
Because of the outletBecause of the outlet
 Anatomic incontinence (UDN-SUI)Anatomic incontinence (UDN-SUI)
 Intrinsic sphincteric IncompetenceIntrinsic sphincteric Incompetence
(Neurogenic or traumatic)(Neurogenic or traumatic)
 CombinationCombination
CombinationCombination
Failure to EmptyFailure to Empty
Because of theBecause of the
BladderBladder
 Hypotonia, Atony.Hypotonia, Atony.
FibrosisFibrosis
Because of the outletBecause of the outlet
 Anatomic ObstructionAnatomic Obstruction
(BPH, Stricture,…)(BPH, Stricture,…)
 Functional:Functional:
Dyssenergia (SmoothDyssenergia (Smooth
or Striated Sphincter)or Striated Sphincter)
CombinationCombination

11. NVD (Neurogenic VoidingNVD (Neurogenic Voiding
DysfunctionsDysfunctions((
DefDef.: NVD are Abnormalities in the.: NVD are Abnormalities in the
micturition cycle produced by differentmicturition cycle produced by different
diseases of the nervous systemdiseases of the nervous system
The NVD depend onThe NVD depend on::
 The level of the neurologic lesionThe level of the neurologic lesion
 The type of neurologic lesionThe type of neurologic lesion
 The status of the UT prior to the lesionThe status of the UT prior to the lesion

12. General Patterns Of NVDGeneral Patterns Of NVD
According To The Level Of The Lesion In The NervousAccording To The Level Of The Lesion In The Nervous
SystemSystem

13. Levels of lesions in NSLevels of lesions in NS
1.1. Above Brain stemAbove Brain stem
2.2. Spinal CordSpinal Cord
 Suprasacral spinal cord Above T6Suprasacral spinal cord Above T6
 Suprasacral spinal cord Below T6 till S2Suprasacral spinal cord Below T6 till S2
CommonestCommonest
 Sacral S2Sacral S2
33. Distal to the spinal cord. Distal to the spinal cord

14. General Patterns Of NVDGeneral Patterns Of NVD
BladderBladder
 Sensation (intact or lost)Sensation (intact or lost)
 Detrusor (Overactive, underactive or atonic)Detrusor (Overactive, underactive or atonic)
OutletOutlet
 Smooth Sphincter (Synergic or dyssenergic)Smooth Sphincter (Synergic or dyssenergic)
 Striated Sphincter (Synergic or dyssenergic)Striated Sphincter (Synergic or dyssenergic)
Specific featuresSpecific features

16. C
S
L
T
T 6
S 2
NDO (Neurogenic DO), Synergic
sphincters, intact sensations and voluntary
sphincters e.g.. CVA
NDO, Synergic smooth sphincter,
Dyssenergic Striated sphincters lost
sensations (after spinal shock) e.g. Trauma
NDO, Dyssenergic Smooth & Striated
sphincters lost sensations +
Autonomic Hypereflexia e.g. Trauma
Areflexia, CNR smooth sphincter, Fixed Striated
sphincters lost sensations
Areflexia, CNR smooth sphincter,
Syn Striated sphincters lost
sensations e.g. Disc
U
M
N
L
L
M
N
L

17. Spinal Cord InjuriesSpinal Cord Injuries
 Spinal Cord ends atSpinal Cord ends at
L1/2 junctionL1/2 junction
 S2,3,4 Opposite T12S2,3,4 Opposite T12
 Injuries at T11 and UpInjuries at T11 and Up
= Suprasacral SCI= Suprasacral SCI
 Injuries at L1 andInjuries at L1 and
Below = Infrascral SCIBelow = Infrascral SCI
 Injuries at T12 =Injuries at T12 =
VariableVariable

18. RemarksRemarks
 These features are the most typical forThese features are the most typical for
each lesioneach lesion
 They represent the common VD with aThey represent the common VD with a
typical lesiontypical lesion
 Variation in the clinical syndrome is veryVariation in the clinical syndrome is very
commoncommon

20. Evaluation of a PatientEvaluation of a Patient
with Neurogenicwith Neurogenic
Voiding DysfunctionVoiding Dysfunction

21. The Neurourologic EvaluationThe Neurourologic Evaluation
History: Stress Points:History: Stress Points:
 History Prior To the current eventHistory Prior To the current event
 LUTS (Storage & Voiding Symptoms)LUTS (Storage & Voiding Symptoms)
 Associated Neurologic SymptomsAssociated Neurologic Symptoms
 Sex and bowel symptomSex and bowel symptom
 Questionnaires and DiariesQuestionnaires and Diaries

22. The Neurourologic EvaluationThe Neurourologic Evaluation
Examination: Stress PointsExamination: Stress Points
UrologicUrologic
-Back: swelling, patches…-Back: swelling, patches…
-Anal tone-Anal tone::
 Intact + voluntary cont=: normal,Intact + voluntary cont=: normal,
 Weak tone and voluntary or absent= sacral andWeak tone and voluntary or absent= sacral and
infrasacral,infrasacral,
 Preserved or increased and no voluntaryPreserved or increased and no voluntary
control= suprasacralcontrol= suprasacral
-P/V-P/V

23. The Neurourologic EvaluationThe Neurourologic Evaluation
Examination: Stress PointsExamination: Stress Points
NeurologicNeurologic
 Mental Status, Gait…Mental Status, Gait…
 Leveling:…Leveling:…
1.1. Motor power:Motor power: Weakness below the lesion +Weakness below the lesion +
Hypertonia in UMNL and Hypotonia in LMNLHypertonia in UMNL and Hypotonia in LMNL
2.2. Sensation:Sensation: Lost below the lesionLost below the lesion
3.3. ReflexesReflexes Knee L 3-4, achilis L5-S2, BCR S2-4Knee L 3-4, achilis L5-S2, BCR S2-4

24. Sensory DermatomesSensory Dermatomes
S2,3,4
L2,3
T 10
L1
T 6

25. Voiding DiaryVoiding Diary
 It is a very important toolIt is a very important tool
 It is no less important than UDNIt is no less important than UDN
 It is the guide forIt is the guide for SelectingSelecting
1.1. the investigationthe investigation
2.2. the UDN testthe UDN test
3.3. the treatmentthe treatment

27. InvestInvest
 Lab….Lab….
 Radiolgic:Radiolgic:
 PUT and U/S, IVPPUT and U/S, IVP
 ACUGACUG
 EndoscopyEndoscopy
 UrodynamicsUrodynamics

28. UrodynamicsUrodynamics

29. Why UrodynamicsWhy Urodynamics??
 Many neurophysiologic defects shareMany neurophysiologic defects share
similar clinical presentations.similar clinical presentations.
 If we treat the clinical condition withoutIf we treat the clinical condition without
respecting the the neurophysiologic statusrespecting the the neurophysiologic status
it might fail but more seriously might beit might fail but more seriously might be
hazardous.hazardous.

30. examplesexamples
 A 65 yrs old man complaining of weak stream notA 65 yrs old man complaining of weak stream not
responding any more to alfa blockers. (which he has beenresponding any more to alfa blockers. (which he has been
taking for 10 years). His PVR is 450 ml and his Qmax istaking for 10 years). His PVR is 450 ml and his Qmax is
6ml/sec.6ml/sec.
 One ptn will benefit very much from TURP and the otherOne ptn will benefit very much from TURP and the other
will not…. why?will not…. why?
 If he has strong detrusor + low flow will benefit fromIf he has strong detrusor + low flow will benefit from
TURPTURP
 If he has a weak detrusor +low flow he will not benefitIf he has a weak detrusor +low flow he will not benefit
from TURPfrom TURP
 These data could not be known except with UDNThese data could not be known except with UDN

31. A 35 yrs old maleA 35 yrs old male
 Had a fracture spine T11-12. IncontinentHad a fracture spine T11-12. Incontinent
always wearing a condom. He does notalways wearing a condom. He does not
feel urgency nor normal desire.feel urgency nor normal desire.
 If you treat the clinical condition: eg AntiIf you treat the clinical condition: eg Anti
cholinergic may end in ---Renal Failure!!!cholinergic may end in ---Renal Failure!!!
 UDN : DO + low bladder capacity DLPPUDN : DO + low bladder capacity DLPP
>40 + DESD so treatment would be…>40 + DESD so treatment would be…

32. 7575yrs old maleyrs old male
 Mild Alzheimer’s complains of severeMild Alzheimer’s complains of severe
frequency nocturia and urge incontinence.frequency nocturia and urge incontinence.
 His stream is very weakHis stream is very weak
 Qmax is 5 on a voided volume of 90 ccQmax is 5 on a voided volume of 90 cc
 His prostate on US is 65 gmHis prostate on US is 65 gm
 He underwent TURP and his conditionHe underwent TURP and his condition
got worse…why?got worse…why?

33. So Urodynamics ToSo Urodynamics To
 To elucidate the neurophysiologicalTo elucidate the neurophysiological
changes that associates the clinicalchanges that associates the clinical
conditioncondition
 1. Complete the evaluation circle1. Complete the evaluation circle
 2. Plan the treatment2. Plan the treatment
 3. Monitor response3. Monitor response

34. UrodynamicsUrodynamics
IndicationsIndications::
 All Neurogenic Voiding DysfunctionAll Neurogenic Voiding Dysfunction
(overt or occult NVD)(overt or occult NVD)
 Selected Cases of Non neurogenic voidingSelected Cases of Non neurogenic voiding
dysfunctiondysfunction

35. Neurogenic VDNeurogenic VD
 OvertOvert: Strokes, Parkinson’s, Spine Injuries,: Strokes, Parkinson’s, Spine Injuries,
Spina bifida overta..Spina bifida overta..
 OccultOccult NVD: Mild dementia, DiabeticNVD: Mild dementia, Diabetic
cystopathy, mild Disc disease, spinal cordcystopathy, mild Disc disease, spinal cord
lesions (tumors, metastasis…),lesions (tumors, metastasis…),

36. Non-Neurogenic VDNon-Neurogenic VD
Clear Voiding DysfunctionsClear Voiding Dysfunctions: BPE, Genuine SUI, Post: BPE, Genuine SUI, Post
prostatectomy incontinence…prostatectomy incontinence…
Rarely will need UDNRarely will need UDN
However UDN is indicated if:However UDN is indicated if:
BPE with CNS disease, Long standing DMBPE with CNS disease, Long standing DM
 SUI mixed wit Urge Incontinence (Mixed UI)SUI mixed wit Urge Incontinence (Mixed UI)
Complicated PPI: to evaluate response to treatmentComplicated PPI: to evaluate response to treatment
Idiopathic VDIdiopathic VD
commonest is IDOcommonest is IDO

37. So…So…
UrodynamicsUrodynamics IndicationsIndications::
 All neurogenic or suspected neurogenicAll neurogenic or suspected neurogenic
VDVD
 Select cases of non-neurogenic VDSelect cases of non-neurogenic VD
 Idiopathic VDIdiopathic VD

38. RememberRemember
 UDN does not treat, it helps you to treat
 UDN does not give you solutions it
answers question for you to give the
solutions

39. That means that before
requesting UDN
1. You have to decide on the questions to
be answered
2. therefore design the study to obtain the
answers to those questions.
3. Correlate the UDN study findings to the
clinical condition

40. )Nitti and Combs, 1998(
 1. Decide on questions to be answered
before starting a study.
 2. Design the study to answer these
questions.
 3. Customize the study as needed.

41. TerminologyTerminology

42. UrodynamicsUrodynamics
What do we want from itWhat do we want from it??
1.1. Is it a storage or emptying defect? orIs it a storage or emptying defect? or
bothboth
2.2. What is the site of the defect? DetrusorWhat is the site of the defect? Detrusor
or outlet or both?or outlet or both?
3.3. What is the type of the defect?What is the type of the defect?
4.4. What is the degree of the defect?What is the degree of the defect?
5.5. How will UDN determine the treatment?How will UDN determine the treatment?

43. UrodynamicsUrodynamics
“Bear in mind“Bear in mind””
NittiNitti’s Principles:’s Principles:
 A study that does not duplicate the ptnA study that does not duplicate the ptn
symptom(s) is not diagnostic.symptom(s) is not diagnostic.
 Failure to record an abnormality does notFailure to record an abnormality does not
rule out its existencerule out its existence
 Not all recorded abnormality are clinicallyNot all recorded abnormality are clinically
significantsignificant

44. UrodynamicsUrodynamics
 Components EvaluationComponents Evaluation
1.1. Storage functionsStorage functions
2.2. Emptying functionsEmptying functions

45. Evaluation of Storage FunctionEvaluation of Storage Function
The Detrusor:The Detrusor:
Filling Cystometry:Filling Cystometry:
 Sensation:1Sensation:1stst
sens., normal desire…..sens., normal desire…..
 Compliance: ∆V/ ∆ PdetCompliance: ∆V/ ∆ Pdet
 Motor activity: pressure rise, UIDC…Motor activity: pressure rise, UIDC…
The outlet:The outlet:
 DLPPDLPP
 VLPPVLPP
 UPPUPP

47. Filling CMGFilling CMG
1st
desire
Normal
desire
Strong
desire Urgency
Max
Cyst
Capacity

48. Filling CMGFilling CMG
 Involuntary BladderInvoluntary Bladder
ContractionsContractions

49. Filling CMGFilling CMG
 ComplianceCompliance
At 155 ml the P det
is 45 cm
= low compliance

50. OutletOutlet
 DLPPDLPP
 40 cm cuttoff40 cm cuttoff

51. OutletOutlet
 VLPPVLPP
Valslava + No Leak
Valsa;va + Leak

53. Evaluation of Voiding FunctionEvaluation of Voiding Function
 UroflowmetryUroflowmetry :: Max flow rate andMax flow rate and
average flow rateaverage flow rate
 Drawbacks!!!Drawbacks!!!
 Siroky NomogramSiroky Nomogram

54. Evaluation of Voiding FunctionEvaluation of Voiding Function
Pressure flow studies:Pressure flow studies:
 Plots the urinary flow against the intravesicalPlots the urinary flow against the intravesical
pressure.pressure.
 Differentiates outflow obstruction from poorDifferentiates outflow obstruction from poor
contractilitycontractility
 Assess the Ext sphincter activity (EMG) at restAssess the Ext sphincter activity (EMG) at rest
and during voidingand during voiding

55. Main abnormalities on VCMGMain abnormalities on VCMG
 Low pressure low flowLow pressure low flow
 High pressure low flowHigh pressure low flow
 High pressure normal flowHigh pressure normal flow
 DESDDESD

56.  Obstructed: Eg: BPEObstructed: Eg: BPE
 Non ObstructedNon Obstructed
Pressure FlowPressure Flow

57. Pressure Flow:Pressure Flow:
NomogramsNomograms

58. DESDDESD

60. VideourodynamicsVideourodynamics
Def:Def: UDN carried out under flouroscopic imagingUDN carried out under flouroscopic imaging
IndicationsIndications::
 When simultaneous evaluation of the structureWhen simultaneous evaluation of the structure
and function of the urinary tract is needed toand function of the urinary tract is needed to
made a diagnosis e.g.made a diagnosis e.g.
 Complex bladder outlet obstruction (bladderComplex bladder outlet obstruction (bladder
neck dysfunction, dyssenergianeck dysfunction, dyssenergia
 Incontinence with unclear pathophysiologyIncontinence with unclear pathophysiology

63. PFS shows high pressure low flow pattern and simultaneousPFS shows high pressure low flow pattern and simultaneous
fluroscopy at start of voiding shows narrowed prostatic fossafluroscopy at start of voiding shows narrowed prostatic fossa

64. RestRest
StressStress
RestRest LeakLeak
VLPP + Fluoroscopic MonitoringVLPP + Fluoroscopic Monitoring

65. Treatment of VDTreatment of VD
 The CauseThe Cause
 The ConditionThe Condition

67. Treatment of VD…GuidelinesTreatment of VD…Guidelines
 IdentifyIdentify the pathologythe pathology
 SelectSelect the appropriate treatment starting with ; thethe appropriate treatment starting with ; the
least invasive most effectiveleast invasive most effective
 DefineDefine Goals?:Goals?:
1.1. Upper UT presevationUpper UT presevation
2.2. Control of infectionControl of infection
3.3. Adequate storage al low intravesical pressureAdequate storage al low intravesical pressure
4.4. Adequate emptying al low intravesical pressureAdequate emptying al low intravesical pressure
5.5. Adequate controlAdequate control
6.6. No catheter or stomaNo catheter or stoma
7.7. Social acceptabilitySocial acceptability

68. Treatment of VD…GuidelinesTreatment of VD…Guidelines
 11stst
: Identify: Identify the problemthe problem

69. Treatment of VD…GuidelinesTreatment of VD…Guidelines
Storage DefectStorage Defect
Because of the BladderBecause of the Bladder
 OveractivityOveractivity
1.1. Involuntary contractionInvoluntary contraction
2.2. Decreased ComplianceDecreased Compliance
3.3. CombinationCombination
 Hypersensitivity (inflam, psych…)Hypersensitivity (inflam, psych…)
Because of the outletBecause of the outlet
 Anatomic incontinence (Genuine SUI)Anatomic incontinence (Genuine SUI)
 Intrinsic sphincteric IncompetenceIntrinsic sphincteric Incompetence
(Neurogenic or traumatic)(Neurogenic or traumatic)
 CombinationCombination
CombinationCombination
Emptying DefectEmptying Defect
Because of theBecause of the
BladderBladder
 Hypotonia, Atony.Hypotonia, Atony.
FibrosisFibrosis
Because of the outletBecause of the outlet
 Anatomic ObstructionAnatomic Obstruction
(BPH, Stricture,…)(BPH, Stricture,…)
 Functional:Functional:
Dyssenergia (SmoothDyssenergia (Smooth
or Striated Sphincter)or Striated Sphincter)
CombinationCombination

70. Botox

83. Botox

84. Thank YouThank You